A draft report on altered fractionation in locally advanced squamous cell carcinoma of the head and neck (SCCHN) was submitted to the Head and Neck Cancer Disease Site Group (DSG). Subsequent feedback from DSG members suggested that there was too much information to be considered in a single guideline. Therefore, two guidelines were developed, one addressing hyperfractionated radiotherapy and the second addressing accelerated radiotherapy. It was suggested that both guidelines include a reference to the recently completed guideline on concomitant chemotherapy and radiation in the same group of patients.
Despite the publication of seven randomized controlled trials comparing hyperfractionated radiotherapy with conventional (daily fractionated) radiotherapy, the DSG expressed concern regarding the quality of the available data. Two of the studies had been published only as abstracts. Information reported by Sanchiz et al and Datta et al was incomplete with respect to the balance of prognostic factors. In addition, Sanchiz et al reported results only for complete responders. There was concern regarding the generalizability of the Brazilian study reported by Pinto et al. Ultimately, only two trials (European Organization for Research and Treatment of Cancer [EORTC] 22791 and Radiation Therapy Oncology Group [RTOG] 9003 provided convincing evidence of improved loco-regional control. The DSG noted that this benefit was not accompanied by improved disease-free or overall survival. A recent update of a third trial demonstrated significantly improved loco-regional control and survival with hyperfractionation, but the result have been reported only in abstract form. There was concern regarding the completeness of reporting of the incidence and severity of late complications in all trials. The DSG members noted the paucity of data on salvage surgery in this group of patients. The group felt that it was premature to conclude that hyperfractionation with dose escalation does not increase late tissue complications.
In comparing the relative merits of hyperfractionation and accelerated fractionation in patients with locally advanced disease, the DSG members noted that there was evidence for improved loco-regional control for both strategies. However, the group rated modestly accelerated regimens somewhat higher because they could improve the therapeutic index without undue pressure on departmental resources. In general, fractionation regimens utilizing two or more fractions per day require more personnel, more machine time, and are more difficult to schedule than conventional daily fractionation. Hyperfractionation leads to a dramatic increase in the number of fractions. In all but one of the published hyperfractionation trials, the number of radiation treatments was doubled in the experimental arm. Because hyperfractionation is resource intensive, DSG members felt that the implementation of hyperfractionation would be difficult in Ontario, particularly in centres where a shortage of machine time contributes to waiting lists.
The DSG members concluded that current information does not support the use of hyperfractionated radiotherapy in adults with locally advanced squamous cell carcinoma of the head and neck at this time. Given the strength of the data supporting concomitant chemoradiation as summarized in the Cancer Care Ontario Practice Guideline Initiative (CCOPGI) practice guideline on concomitant chemotherapy and radiotherapy in SCCHN, the DSG members concluded that concomitant chemoradiation should be regarded as the treatment of first choice in patients with locally advanced SCCHN.
